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Pacific Prime - IHI Bupa International Health and Hospital Plan Application Form
 

Pacific Prime - IHI Bupa International Health and Hospital Plan Application Form

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IHI Bupa offer a variety of Health Insurance products. This is the application form for their International Health and Hospital Plan, in partnership with Pacific Prime Insurance Brokers.

IHI Bupa offer a variety of Health Insurance products. This is the application form for their International Health and Hospital Plan, in partnership with Pacific Prime Insurance Brokers.

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    Pacific Prime - IHI Bupa International Health and Hospital Plan Application Form Pacific Prime - IHI Bupa International Health and Hospital Plan Application Form Document Transcript

    • I n t e r n at i o n a l H e a lt h a n d H o s p i ta l P l a n A pp l icati o n F o rm A Pacific Prime International Limited.(Please use block letters) F o r a d m i n i s t r at i o n u s e Ref. Policy Number - Date # C o m m e n c e m e n t d at e * I / we request that the policy commences from day 0 1 month year *We will confirm to you the commencement date of your policy. Waiting periods may apply as set out in your policy conditions. Policyholder First name(s) Sex (M/F) Family name(s) Date of birth (day/month/year) Fax Email Telephone Mobile phone Address Address Postal Code City Country D e p e n da n t s First name(s) Date of birth (day/month/year) Family name(s) Sex (M/F) First name(s) Date of birth (day/month/year) Family name(s) Sex (M/F) First name(s) Date of birth (day/month/year) Family name(s) Sex (M/F) First name(s) Date of birth (day/month/year) Family name(s) Sex (M/F) Reimbursement via bank transfer If you would like us to transfer future reimbursements to your bank account, please state: Account holder’s name(s) Name of bank Bank address Postal Code City Country Transfer to Danish account: Reg. No. Account No. Transfer to foreign account: Account No./IBAN No. Swift No. Preferred reimbursement currency Please state currency ihi Bupa ° Customer Service ° Palægade 8 ° DK-1261 Copenhagen K ° Denmark ° Tel: +45 70 23 00 42 ° Fax: +45 33 32 25 60 ° Email: ihi@ihi.com ° www.ihi.com Medical Centre: +45 70 23 24 60 / Email: emergency@ihi.com ihi Bupa is a trading name of Bupa Insurance Limited. Registered in England No. 3956433. Registered office: Bupa House, 15-19 Bloomsbury Way, London WC1A 2BA, UK Bupa Insurance Limited is authorised and regulated by the Financial Services Authority (UK)
    • Pa p e r l e s s c u s t o m e r s i g n u p I hereby sign up as a paperless customer with ihi Bupa. As a paperless customer, I will receive all documents and correspondence from ihi Bupa via my personal myPage on www.ihi.com. I understand that I will not receive any hardcopies of documents to my postal or collection address and that it will be my responsibility to check all documents and correspondence online and to inform ihi Bupa of any changes to my email address. I can get more information on www.ihi.com/services.I n t e r m e d i a r y ’ s a cc e s s t o d o c u m e n t s In the event that I am represented by an intermediary, I hereby accept that my intermediary will get access to my documents online onq his/her personal and secure ihi Bupa website.Cover – please choose modules, currency and deductible by ticking the relevant boxesChoice of modules Choice of deductible / currency Hospital Plan Nil Nil Nil Module 1 - Non-Hospitalisation Benefits EUR 350 GBP 250 USD 400 Module 2 - Medicine & Appliances EUR 1,050 GBP 750 USD 1,600 Module 3 - Medical Evacuation & Repatriation EUR 4,000 GBP 2,750 USD 5,000 Module 4A - Dental & Optical EUR 8,000 GBP 5,500 USD 10,000 Module 4B - Dental & Optical EUR 16,000 GBP 11,000 USD 20,000 Please note that the chosen currency is bindingP r e m i u m pay m e n t Annual Semi-annual QuarterlyR e q u e s t f o r pay m e n t f r o m a b a n k o r a n o t h e r a d d r e s s , i f d i ff e r e n t f r o m r e s i d e n t i a la d d r e s s (Not possible for paperless customers)Name(s)AddressAddressPostal Code CityCountryAccount No. (if bank)R e q u e s t f o r pay m e n t b y i n t e r n at i o n a l c r e d i t c a r dI / we wish to pay the premium via credit card. Bupa Insurance Limited (ihi Bupa) will charge the credit card directly. AmericanExpress Visa Eurocard / Mastercard JCB DinersCard no.Expiry date (m/y) CVC code**CVC code: The last three/four digits after the card number on the back of the card or the last three digits in the signature field.Cardholder’s data if cardholder and policyholder are not the same person:Name(s)AddressAddressPostal Code CityCountry 211E3-41v1.1_IHHP_ENG_App A I also authorise Bupa Insurance Limited (ihi Bupa) until further notice in writing, to charge my credit card account with unspecified amounts in respect of my premium payments as and when these become due. ihi Bupa will inform me in advance of any premium adjustments.Cardholder’s signature Date ihi Bupa ° Customer Service ° Palægade 8 ° DK-1261 Copenhagen K ° Denmark ° Tel: +45 70 23 00 42 ° Fax: +45 33 32 25 60 ° Email: ihi@ihi.com ° www.ihi.com Medical Centre ° Tel: +45 70 23 24 60 ° Tel: Email: emergency@ihi.com ihi Bupa is a trading name of Bupa Insurance Limited. Registered in England No. 3956433. Registered office: Bupa House, 15-19 Bloomsbury Way, London WC1A 2BA, UK Bupa Insurance Limited is authorised and regulated by the Financial Services Authority (UK)
    • ihi Bupa M edical Q uestionnaire(Please use block letters)Please read the information regarding the underwriting conditions in Section A before completing this “Medical Questionnaire”. A ) U nder w ritin g C onditions Please see the below stated underwriting conditions for new applicants who would like to apply for cover and existing customers who want to apply for an upgrade in cover. Further we refer to the Policy Conditions stated in the product guide of the insurance product you are applying for. Please note that you always have to complete a “Medical Questionnaire” for adopted children, children born as a result of fertility treatment and children born by a surrogate mother. International Health and Hospital Plan: A “Medical Questionnaire” must be completed for each person aged 10 years or over applying for cover and any child under the age of 10 with a pre-existing condition or who is not in good health. All the “Medical Questionnaires” should be sent together with the “Application Form A” to the insurer. International Swiss Medical: A “Medical Questionnaire” must be completed for each person applying for cover. All the “Medical Questionnaires” should be sent together with the “Application Form A” to the insurer*. International Top Up Plan: A “Medical Questionnaire” must be completed for each person aged 16 years or over applying for cover, and any child under the age of 16 with a pre-existing condition or who is not in good health. All the Medical Questionnaires should be sent together with the “Application Form A” to the insurer. Superior: A “Medical Questionnaire” must be completed for each person aged 10 years or over applying for cover or any child under the age of 10 with a pre-existing condition or who is not in good health. All the “Medical Questionnaires” should be sent together with the “Application Form A”. Worldwide Health Insurance: A “Medical Questionnaire” must be completed for each person aged 16 years or over applying for cover, and any child under the age of 16 with a pre-existing condition or who is not in good health. All the “Medical Questionnaires” should be sent together with the “Application Form A” to the insurer. *Please be aware of the special underwriting condition for new applicants with a Sanitas agreement. B ) General information For administration use Policy number — Date (dd/mm/yy) Broker number Applicant (Please underline the names you wish to be indicated on your insurance card. Max. 28 fields) First name(s) Family name(s) Occupation Date of birth (day/month/year) Age Sex (M/F) Nationality Other insurance Do you have a health insurance with a Bupa group company or another insurance company? YES NO Have you ever had a health insurance with a Bupa group company or another insurance company? YES NO Company name Policy number Do you intend to keep your current insurance? YES NO Have you ever had an application for health or life insurance declined or accepted subject YES NO to exclusions or at a premium above the insurer’s standard rates?If yes, please enclose complete information (Policy Conditions and policy documents) Family doctor/treating physician Name Address Telephone Fax Email
    • Family name Date of birth (dd/mm/yy)C ) M E D I C A L I N F O R M AT I O N Q U E S T I O N N A I R EThis section asks for health and medical details - known (past and present) and suspected conditions. Please tick yes or no to every question1-17 and provide answers to questions 18-22. If you tick yes to any of the questions 1-17 in this Medical Information Questionnaire, please givefull details in Section D Additional Information. Please ensure that you tell us about any known or suspected conditions and symptoms even ifprofessional advice has not yet been sought. If you already are an ihi Bupa customer and you are applying to increase cover or you are applyingto transfer from another Bupa group product, please include details of any conditions for which you have made claims since joining.1) Heart or circulatory disorders eg high blood pressure, angina/chest pains, heart attack, heart failure, abnormal heart beat, aneurysms, YES NO varicose veins, other related symptoms/diseases2) Endocrine (glandular disorders) eg obesity, thyroid problems, diabetes type 1, diabetes type 2, colitis, liver diseases, liver cirrhosis other YES NO related symptoms/diseases3) Breathing or respiratory disorders eg asthma, COPD, shortness of breath, pneumonia, bronchitis, tuberculosis, allergies (including hayfever YES NO and anaphylaxis), chest infections, other related symptoms/diseases4 ) Stomach, intestines, liver or gall bladder problems eg stomach inflammation/ulcers, irritable bowel, Crohn’s disease, colitis, cirrhosis, abdominal pain, change in bowel habits, pancreatitis, hernias, liver inflammation, gall stones, haemorrhoids/piles, other YES NO related symptoms/diseases5) Cancer, tumours or growths eg polyps, benign growths, any cancers or pre-cancerous conditions, other symptoms/diseases YES NO6) Skin problems eg allergic conditions, rashes, psoriasis, acne, cysts, moles that itch or bleed, dermatitis, eczema, other YES NO related symptoms/diseases7) Brain or nervous system disorders eg stroke, dementia, migraine, repeated headaches, multiple sclerosis, nerve pain (including sciatica and YES NO shingles), epilepsy/fits, meningitis, other related symptoms/diseases8) Muscle or skeletal problems eg arthritis, back pain, neck/shoulder problems, cartilage and ligament problems, joint replacements, YES NO fractures, gout, osteoporosis, inflammatory conditions, other related symptoms/diseases9) Urinary or reproductive system problems eg kidney or bladder problems (including kidney failure), recurrent urinary infections, incontinence, pregnancy/childbirth problems (including caesarean sections), heavy or irregular periods, fibroids, YES NO infertility/fertility treatment, endometriosis, sexually transmitted infections, polycystic ovaries, testicular or prostate disorders, abnormal smears, other related symptoms/diseases1 0 ) Blood/infective/immune disorders eg abnormal blood tests, high cholesterol, anaemia, hepatitis A-B-C, malaria, any autoimmune disorder, YES NO HIV, other related symptoms/diseases1 1 ) Eye, ear, nose, throat and dental problems eg cataracts, glaucoma, visual impairment, ear infections, deafness, tonsillitis, wisdom teeth problems, YES NO dental infections, gingivitis, other related symptoms/diseases1 2 ) Psychiatric/psychological disorders eg compulsive or eating disorders, schizophrenia, depression, stress, anxiety, drug/alcohol dependency, NO YES other related symptoms/diseases1 3 ) Cosmetic operations YES NO1 4 ) Other diseases, disorders or llnesses YES NO1 5 ) Are you or have you been taking any medication, prescribed or otherwise? YES NO1 6 ) Are you receiving any treatment of any kind, or do you require or expect to require any review, investigations or treatment for any current or past medical problem not YES NO already mentioned in this application?1 7 ) Have you experienced any signs or symptoms of any medical problem in the last YES NO six months, regardless of whether a health care professional has been consulted?
    • Family name Date of birth (dd/mm/yy) C) M E D I C A L I N F O R M AT I O N Q U E S T I O N N A I R E (continued) 18) Height Metres/Centimetres Feet/Inches 19) Weight Kilogrammes Stones/Pounds 20) For women only: Are you currently pregnant? YES NO 21) Smoking Do you smoke? YES NO If yes, how many cigarettes/day? 22) Do you use spectacles or contact lenses? YES NO — if yes please indicate strength in diopter, left eye right eye D ) A dditional information This section applies if you have indicated “Yes” to any questions in section C. If you are unsure whether any details are relevant, you must include them. Please enter the question number (Questions 1-17 that you have answered YES to on the Medical Information Questionnaire) Please specify as accurately as possible the name of the illness or medical problem. Where applicable, please state the area of the body affected, (eg right leg, left eye): When did the symptoms start and when was treatment completed? What treatment did you receive and when (please include dates, names and details of medications)? What was the outcome of the treatment (eg ongoing, complete recovery, recurrent or likely to recur)? Please enter the question number (Questions 1-17) that you have answered YES to on the Medical Information Questionnaire) Please specify as accurately as possible the name of the illness or medical problem. Where applicable, please state the area of the body affected, (eg right leg, left eye): When did the symptoms start and when was treatment completed? What treatment did you receive and when (please include dates, names and details of medications)? What was the outcome of the treatment (eg ongoing, complete recovery, recurrent or likely to recur)? 23) Additional information: Do you have additional medical information? YES NO All relevant up-to-date medical reports should be enclosed in the event of any pre-existing medical conditions.NB If you experience any additional symptoms other than the above described before you receive your policy documents, please notify us immediately.Failure to do so may affect your cover.If there is insufficient space, please use a separate sheet and indicate that you have done so by ticking hereIf you have ticked here, please indicate how many pages you have attached to this Medical Questionnaire __________
    • Family name Date of birth (dd/mm/yy) 991E3-42v1.1_Generic_ENG_App B E ) A pplicant ’ s si g nature Your declaration Claims and other benefits may not be payable, and in some cases the insurance may even be void, if you do not fully disclose any material fact which could influence our assessment and acceptance of this application. If you are in any doubt as to whether any facts are material, you should disclose them. You are advised to keep a record of all information you supply to us in connection with this application, including letters. If your health changes after the application has been signed but before an insurance agreement has been entered into with Bupa Insurance Limited (“ihi Bupa”), you must notify ihi Bupa immediately of such change. You may be required to provide ihi Bupa with medical reports in relation to this and any other pre-existing conditions. In view of the following declaration, it is essential that complete information is supplied. I declare that to the best of my knowledge and belief the information given by me is true and complete, and that, apart from the conditions fully disclosed to ihi Bupa, I and any children (“dependants”) to be insured on my policy are in excellent health and do not suffer or have suffered from any recurring illness or physical debility. If insurance for dental treatment is required, neither myself nor my dependants are under or about to undergo dental treatment. I declare that I (on my and my dependants’ behalf) have read the Policy Conditions and this Medical Questionnaire, and accept that the Policy Conditions together with the Policy Schedule (and the application forms) will represent the insurance contract with ihi Bupa. I also declare that I and my dependants are not permanently resident in the USA. I confirm that I (on my and my dependants’ behalf) have read the Data Protection Notice below, and give explicit consent for ihi Bupa to use my and my dependants’ personal information in the manner and for the purposes stated. Data Protection Notice Purpose: Personal data collected about you and your dependants will be used by ihi Bupa to process your claims, collect premium, provide reimbursements, administer your policy and to detect and prevent fraud or improper claims. If ihi Bupa does not accept your application, your information may be recorded by us. Confidentiality: ihi Bupa complies with applicable data protection legislation and medical confidentiality guidelines. All correspondence concerning your policy will be sent to the policyholder and may be sent via your intermediary. All insured persons on the policy may have access to correspondence and other information sent by ihi Bupa or accessed at www.ihi.com via the myPage login. ihi Bupa uses third parties to process data on its behalf and your data may be processed in or outside the EU. ihi Bupa may exchange your information within the Bupa group and with your intermediary. If you have had a health insurance with a Bupa group company or another insurance company ihi Bupa may collect your medical information from this company and exchange information with the company in order to assess your current insurance application. Medical information: ihi Bupa may seek and exchange information about your and your dependants’ health and treatment with those involved in your and your dependants’ care (including your treating doctor and hospital) and their agents, and, if applicable, any person or organisation who may be responsible for meeting your and your dependants’ treatment expenses, or their agents, as ihi Bupa deems necessary. Telephone calls: In the interest of continuously improving our service to customers, your call will be recorded and may be monitored. Research: Anonymised or aggregated data may be used by ihi Bupa, or disclosed to others, for research or statistical purposes. Fraud: Information, including recorded telephone calls, may be disclosed to others with a view to preventing or detecting fraudulent or improper claims. Names and addresses: ihi Bupa does not make the names and addresses of customers available to other organisations (except as stated above). Keeping you informed: ihi Bupa will, on occasion, keep you informed of its products and services which it considers may be of interest to you. Data protection legislation gives you the right to see documents and information ihi Bupa has recorded about you. Contact address: If you do not wish to receive information about our products and services, or would like to see a copy of the information we hold about you, please write to the Bupa Group Information Protection Manager at Bupa House, 15-19 Bloomsbury Way, London WC1A 2BA, England or at DataProtection@Bupa.com. Date (day/month/year) Signature ihi Bupa ° Customer Service ° Palægade 8 ° DK-1261 Copenhagen K ° Denmark ° Tel: +45 70 23 00 42 ° Fax: +45 33 32 25 60 ° Email: ihi@ihi.com ° www.ihi.com Medical Centre ° Tel: +45 70 23 24 60 ° Tel: Email: emergency@ihi.com ihi Bupa is a trading name of Bupa Insurance Limited. Registered in England No. 3956433. Registered office: Bupa House, 15-19 Bloomsbury Way, London WC1A 2BA, UK Bupa Insurance Limited is authorised and regulated by the Financial Services Authority (UK)
    • Contact InformationWhy do we need this? We are here to assist you in the long term, with support on all administration, renewal and claims issues.We request this form to be completed so we can contact you/your next of kin in case of emergencies or urgent policy issues.People often forget to update their policy details when they move house or change employer and the below information helpsus to manage your policy better.Please help us to achieve this by keeping us fully informed of any future changes in your contact details as soon as possible.Pacific Prime guarantees your privacy, only using this information internally regarding issues relating to your, or your family’s,personal insurance; will not provide this information to any third parties for commercial reasons.Policyholder Spouse s Mr Mrs Ms Miss Other: Mr Mrs Ms Miss Other:Family Name: Family Name:Given Name: Given Name:MiddleName(s): MiddleName(s):Country: Country:Home Address: Home Address:Contact info in the country you now live in Contact info in the country you now live inMobile: Mobile:Home: Home:Work: Work:Personal email (1): Personal email (1):Personal email (2): Personal email (2):Work email: Work email:Employer: Employer:Country: Country:Employers Address: Employers Address:Permanent contact informationCountry: Country:Mobile: Mobile:Home/Work: Home/Work:Email: Email:Facebook:Twitter:Skype:Google+:Emergency Contact PersonIn the event of an emergency whereby we are unable to contact you or your spouse or should you beincapacitated then please provide us with the permanent contact details of an immediate family memberwho we should contact in this situation.Family Name: Email:Given Name: Relationship to you:MiddleName(s): Country:Mobile: Home Address:Home:Work: